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					       Module 4              Recommending exercise to patients with diabetes
                             (Adopted from Department of Health
                             Exercise Prescription 2011 Edition)


         A. Effects of Exercise

         Regular exercise has been shown to improve blood glucose control, reduce
         cardiovascular risk, contribute to weight loss, and improve well being. Furthermore,
         regular exercise may prevent Type 2 Diabetes Mellitus (T2DM) in high-risk
         individuals. Moderate-intensity (e.g. brisk walking) to vigorous-intensity exercises
         of ≥150 min per week have been proven to confer significant benefits in the
         prevention of T2DM onset (A risk reduction of 46 % in the Da Qing Study in
         mainland China, and by 58 % in the Diabetes Prevention Program in the United
         States.) 1-3 Recent follow-up studies suggest that this risk reduction can be
         sustained over a prolonged period4. Structured exercise interventions of at least
         8 weeks’ duration have been shown to lower A1C by an average of 0.66% in
         people with T2DM, even with no significant change in body mass index5. While
         higher levels of exercise intensity are associated with greater improvements in
         A1C and fitness, milder forms of physical activities, like yoga and tai chi, may
         also benefit control of blood glucose 6-9.

         Progressive resistance exercise improves insulin sensitivity in older men with
         T2DM to the same or even greater extent as aerobic exercise10. Clinical trials
         have provided strong evidence for the A1C-lowering value of resistance exercise
         in older adults with T2DM and for an additive benefit of combined aerobic and
         resistance exercise in adults with T2DM11-13. Resistance exercise also enhances
         skeletal muscle mass and endurance, and hence may reduce the risk of fall in
         these elderly14.




1   HK Reference Framework for Diabetes Care for Adults in Primary Care Settings
                        Module 4   Recommending exercise to patients with diabetes (Adopted
                                   from Department of Health Exercise Prescription 2011 Edition)




B. Recommendations for Exercise Prescription

The Global Recommendations on Physical Activity for Health published by the
World Health Organization in 2010 specify that adults over 18 years of age should
perform at least 150 min per week of moderate-intensity or 75 min per week of
vigorous-intensity aerobic physical activity or an equivalent combination of the
two. The recommendations further suggest adults to perform muscle-strengthening
activities involving all major muscle groups two or more days per week. Adults
over 65 years of age are advised to follow the adult recommendations if possible
or (if this is not possible) be as physically active as they are able. Studies included
in the meta-analysis of effects of exercise interventions on glycaemic control had
a mean number of sessions per week of 3.4, with a mean of 49 min per session5.
The Diabetes Prevention Program lifestyle intervention, which involved 150 min
per week of moderate-intensity exercise, had a beneficial effect on glycaemic
control in those with pre-diabetes1. Therefore, it seems reasonable to recommend
people with T2DM to follow the same physical activity recommendations for
the general population.




                         HK Reference Framework for Diabetes Care for Adults in Primary Care Settings   2
           Module 4    Recommending exercise to patients with diabetes (Adopted
                       from Department of Health Exercise Prescription 2011 Edition)




           The following table summarizes the exercise prescription that is recommended
           for patients with T2DM.

    Physical
    Activity                                            Recommendations*
     Profile

    Frequency         ● Perform moderate to vigorous aerobic exercise spread out at least 3 days during
                        the week, with no more than two consecutive days between bouts of activity 14.
                      ● Undertake resistance exercise at least twice weekly on nonconsecutive days, but more
                        ideally three times a week, along with regular aerobic exercise14.

    Intensity         ● Aerobic exercise should be at least at moderate intensity (e.g. brisk walking),
                        corresponding approximately to 40%–60% of maximal aerobic capacity (VO2 max)14.
                        Relatively, moderate-intensity activity could be expressed as a level of effort of 5
                        or 6 on a scale of 0 to 10 (where 0 is the level of effort of sitting, and 10 is maximal
                        effort) or 50–70% of maximum heart rate15-17.
                      ● Additional benefits may be gained from vigorous aerobic exercise (i.e. >60% of
                        VO2 max)14. Relatively, vigorous-intensity activity could be expressed as a level
                        of effort of 7 or 8 on a scale of 0 to 10 or 70–90% of maximum heart rate15-16.
                      ● R esistance exercise should be moderate (>50% of 1-repetition maximum,
                        i.e.1-RM– maximum amount of weight one can lift in a single repetition for a
                        given exercise) or vigorous (75–80% of 1-RM) at intensity14.


    Time              ● 20 to 60 min per day of aerobic exercise should be performed continuously
                        or intermittently in bouts of at least 10 min accumulated to total 150 min per week14,18.
                      ● 3 sets of 8–10 repetitions on 8–10 exercises involving the major muscle groups
                        may be an optimal goal for resistance exercise14.


    Type              ● A variety of modes of aerobic exercise is recommended but any form (including
                        brisk walking) that uses large muscle groups and causes sustained increases
                        in heart rate (HR) is likely to be beneficial14. Exercises like walking, swimming
                        or cycling that do not impose undue stress on the feet are some appropriate choices.
                      ● Each session of resistance exercise should involve the major muscle groups (legs,
                        hips, chest, back, abdomen, shoulders, and arms). According to the literature,
                        resistance exercise programme involving a combination of bench press, leg
                        extension, upright row, lateral pull-down, standing leg curl (ankle weights),
                        dumbbell seated shoulder press, dumbbell seated biceps curl, dumbbell triceps
                        kickback, and abdominal curls has been shown to improve glycaemic control in
                        older adults with T2DM 11.


           * Given that many patients may present with comorbidities, it may be necessary to
           tailor the exercise prescription accordingly.



3    HK Reference Framework for Diabetes Care for Adults in Primary Care Settings
                      Module 4   Recommending exercise to patients with diabetes (Adopted
                                 from Department of Health Exercise Prescription 2011 Edition)




Initial instruction and periodic supervision by a qualified exercise trainer is
recommended for most persons with T2DM, particularly if they undertake
resistance exercise, to ensure optimal benefits to blood glucose control, blood
pressure, lipids, and cardiovascular risk and to minimize injury risk 19.

C. Rate of Progression

Gradual progression of intensity of aerobic exercise is advisable to minimize
the risk of injury, particularly if health complications are present, and to
enhance compliance 14 . Points to be taken into consideration in exercise
prescription include age, ability, disease state, and individual preference of
type of exercise – in general, the elderly and obese patients with T2DM take
longer time for adaptation and may require slower progression, though it is
advisable for the aged to be as physically active as possible.

Similarly, to avoid injury, progression of frequency and intensity of resistance
exercise should occur slowly. Increases in weight or resistance are undertaken
first and only once when the target number of repetitions per set can consistently
be exceeded, followed by a greater number of sets and lastly by increased
frequency 14 . Early in training, each session of resistance exercise should
minimally include 5–10 exercises and involve completion of 10–15 repetitions
to near fatigue per set, progressing over time to heavier weights (or resistance)
that can be lifted only 8–10 times. A minimum of one set of repetitions to
near fatigue for each exercise, but as many as 3 to 4 sets, is recommended for
optimal strength gains14 .




                       HK Reference Framework for Diabetes Care for Adults in Primary Care Settings   4
         Module 4    Recommending exercise to patients with diabetes (Adopted
                     from Department of Health Exercise Prescription 2011 Edition)




         D. Evaluation of the diabetic patient before recommending an
         exercise programme

         Medical practitioners should use clinical judgment in this area. Certainly, high-risk
         patients should be encouraged to start with short periods of low-intensity exercise
         and to increase the intensity and duration slowly. Medical practitioners should
         assess patients for conditions that might contraindicate certain types of exercise
         or predispose to injury, such as uncontrolled hypertension, severe autonomic
         neuropathy, severe peripheral neuropathy or history of foot lesions, and unstable
         proliferative retinopathy as well as take into consideration patients’ age and
         previous physical activity levels 17.

         Exercise stress testing is not routinely recommended to detect ischaemia in
         asymptomatic individuals at low coronary heart disease (CHD) risk (<10 % in
         10 yrs.). It is advised primarily for sedentary adults with diabetes who are at
         higher risk for CHD and who would like to undertake activities more intense
         than brisk walking, e.g. age >40, concomitant risk factors such as hypertension,
         microalbuminuria, etc., or presence of advanced cardiovascular or microvascular
         complications (e.g. retinopathy, nephropathy) 14.




5   HK Reference Framework for Diabetes Care for Adults in Primary Care Settings
                       Module 4   Recommending exercise to patients with diabetes (Adopted
                                  from Department of Health Exercise Prescription 2011 Edition)




E. Exercise in the presence of non-optimal glycaemic control

1. Hyperglycaemia.
   When people with type 1 diabetes are deprived of insulin and are ketotic,
   exercise can worsen hyperglycaemia and ketosis; therefore, vigorous activity
   should be avoided in the presence of ketosis20. On the other hand, T2DM
   subjects usually are not profoundly insulin-deficient. They do not have to
   postpone exercise simply because of high blood glucose (e.g. > 16.7 mmol/L),
   as long as they feel well, and are adequately hydrated without ketosis 14.

2. Hypoglycaemia.
   In individuals with T2DM performing moderate exercise, blood glucose
   utilization by muscles usually rises more than hepatic glucose production,
   and blood glucose levels tend to decline. Plasma insulin levels normally fall,
   however, making the risk of exercise-induced hypoglycaemia in anyone not
   taking insulin or insulin secretagogues very minimal, even with prolonged
   physical activities14. In individuals taking insulin and/or insulin secretagogues
   (e.g. sulfonylureas like glyburide, glipizide, and glimepiride, as well as
   nateglinide and repaglinide), physical activity can cause hypoglycaemia if
   medication dose or carbohydrate consumption is not altered. For individuals
   on these therapies, added carbohydrate should be ingested if pre-exercise
   glucose levels are 5.6 mmol/L 21-22. Hypoglycaemia is rare in diabetic
   individuals who are not treated with insulin or insulin secretagogues, and no
   preventive measures for hypoglycaemia are usually advised in these cases.




                        HK Reference Framework for Diabetes Care for Adults in Primary Care Settings   6
         Module 4    Recommending exercise to patients with diabetes (Adopted
                     from Department of Health Exercise Prescription 2011 Edition)




         F. Exercise in the presence of specific long-term complications
         of diabetes

         1. Retinopathy
            In the presence of proliferative diabetic retinopathy or severe non-proliferative
            diabetic retinopathy, vigorous aerobic or resistance exercise may be contraindicated
            because of the risk of triggering vitreous haemorrhage or retinal detachment 23.

         2. Peripheral neuropathy
            Decreased pain sensation in the extremities results in increased risk of skin
            breakdown and infection and of Charcot joint destruction and this is why some
            prior recommendations have advised non-weight-bearing exercise for patients
            with severe peripheral neuropathy. Studies have shown that moderate-intensity
            walking may not lead to increased risk of foot ulcers or re-ulceration in those
            with peripheral neuropathy 24. Individuals with peripheral neuropathy and
            without acute ulceration may participate in moderate weight-bearing exercise 14.
            Comprehensive foot care including daily inspection of feet and use of proper
            footwear is recommended for prevention and early detection of sores or
            ulcers14. Anyone with a foot injury or open sore should confine themselves to
            non-weight-bearing activities.

         3. Autonomic neuropathy
            Autonomic neuropathy can increase the risk of exercise-induced injury or
            adverse events through decreased cardiac responsiveness to exercise, postural
            hypotension, impaired thermoregulation, impaired night vision due to impaired
            papillary reaction, and unpredictable carbohydrate delivery from gastroparesis
            predisposing to hypoglycaemia25. Autonomic neuropathy is also strongly
            associated with cardiovascular disease in people with diabetes 26-27. People
            with diabetic autonomic neuropathy should be screened and receive physician
            approval and possibly an exercise stress test before embarking on physical
            activity levels more intense than usual. Exercise intensity is best prescribed
            using the HR reserve method with direct measurement of maximal HR 14.




7   HK Reference Framework for Diabetes Care for Adults in Primary Care Settings
                       Module 4   Recommending exercise to patients with diabetes (Adopted
                                  from Department of Health Exercise Prescription 2011 Edition)




4. Albuminuria and nephropathy
   Physical activity can acutely increase urinary protein excretion. However,
   there is no evidence that vigorous exercise increases the rate of progression of
   diabetic kidney disease and likely no need for any specific exercise restrictions
   for people with diabetic kidney disease28. Exercise increases physical function
   and QOL in individuals with kidney disease and may even be undertaken
   during dialysis sessions.




                        HK Reference Framework for Diabetes Care for Adults in Primary Care Settings   8
         Module 4    Recommending exercise to patients with diabetes (Adopted
                     from Department of Health Exercise Prescription 2011 Edition)




         Reference:
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             Walker EA, et al. Reduction in the incidence of type 2 diabetes with lifestyle
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         4. Li G, Zhang P, Wang J, Gregg EW, Yang W, Gong Q, et al. The long-term
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9   HK Reference Framework for Diabetes Care for Adults in Primary Care Settings
                       Module 4   Recommending exercise to patients with diabetes (Adopted
                                  from Department of Health Exercise Prescription 2011 Edition)




11. Dunstan DW, Daly RM, Owen N, Jolley D, De Courten M, Shaw J, et al.
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                        HK Reference Framework for Diabetes Care for Adults in Primary Care Settings   10
          Module 4    Recommending exercise to patients with diabetes (Adopted
                      from Department of Health Exercise Prescription 2011 Edition)




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11   HK Reference Framework for Diabetes Care for Adults in Primary Care Settings

				
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Description: Office of the crowd have a sense of increasing their activity levels. You can participate in exercise between work, can work intermittently, from time to time stretching gymnastics, activities, neck shoulder and waist, up and move about, and promote blood circulation of lower limbs. Often keystrokes you can do shake a finger movement, so relax tense fingers.